This review forms part of the TALE and What About Us? projects (https://www.athletes-tale.eu), which were developed in response to the recognition that while considerable attention is devoted to detecting and sanctioning doping, comparatively little is directed toward the human cost of these actions. The projects were conceptualized following the introduction of WADA's International Standard for Education, which states that evidence-informed education should be provided to athletes returning from an ADRV sanction (5). Aiming to contribute to these discussions, the projects seek to identify research gaps and generate evidence to inform policy recommendations and practical guidelines that better prepare emerging athletes and support those facing sanctions.

The authors of this review bring a diverse and complementary range of expertise spanning psychology, sport psychology, sport science, public health, sports business management, and social science–focused anti-doping research. The first author, with a background in sport psychology and sports business management, brings experience in document analysis and evidence synthesis. The second, third, fourth and sixth authors are established experts in social science–focused anti-doping research, recognized internationally for their contributions to the field. The second, third, fifth, and sixth authors have contributed to research examining the lived experience of athletes sanctioned under the WADC, including outputs reviewed as part of this study. These collective perspectives are strengthened by the fourth author, a former professional athlete and anti-doping researcher with a background in sports management and social science.

Prioritizing the practical consequences and the real-world implications of anti-doping sanctioning, our work is grounded in a pragmatist research philosophy (27). As a multidisciplinary team, the authorship group acknowledges that our interpretations of the reviewed outputs are shaped by both proximity to and critical engagement with the anti-doping system. These perspectives provide valuable contextual sensitivity but also position us within a field where regulatory narratives, athlete welfare, and institutional credibility coexist in tension. Adopting a pragmatist stance allows us to balance these influences by focusing on the lived consequences of ADRVs to inform and improve regulatory practices. Our aim is neither to defend nor to discredit the anti-doping system, but to generate actionable insights that support fair processes to all involved and reduce unintended harms. This orientation recognizes the complex, high-stakes environment in which anti-doping operates and foregrounds the experiences of those most affected, while remaining attentive to gaps, uncertainties, and the limitations inherent in the available evidence.

Initially, a keyword-based search strategy was developed to identify relevant outputs. However, this strategy proved unsuitable as despite multiple revisions, searches consistently generated large numbers of irrelevant results and failed to retrieve outputs previously identified by the research team (Supplementary Table 1.1). In response, an iterative multi-phase search strategy was developed and adopted, consistent with exploratory literature review style inquires (28–30).

The output identification process involved:

Existing knowledge: Cataloguing relevant literature known to the authorship group;

Following the completion of the output selection process, a quality assessment was conducted on the included outputs. This phase did not affect inclusion decisions and was not used to judge the inherent value of the outputs. Rather, the assessment examined adherence to best-practice standards for reporting qualitative data. The tool presented by Lockwood et al. (31) was adopted to complete this assessment because it was specifically designed for this purpose. Five authors (first, second, fourth, fifth, and sixth) independently scored eleven outputs using the tool, with responses coded as yes (1), no (0), unclear (0.5), or not applicable (missing). Given the format of Jamieson and Ordway (32), a case study presented in a book chapter, this output was excluded from the quality assessment (Supplementary Table 2.1).

Independent ratings were compiled, and interrater reliability was assessed by the second author using Fleiss’ kappa (33) and weighted Cohen's kappa for pairwise agreement (34). Discrepancies in ratings across outputs were discussed among the five authors to allow alternative interpretations of the appraisal criteria to be considered (Supplementary Table 2.2). The third author, an expert in qualitative methodologies, reviewed the four outputs with the highest inconsistency in the rating to provide a benchmark during these discussions. Consensus was not enforced, and differing views were retained where appropriate. Following this process, interrater reliability was reassessed and reported (Supplementary Table 2.3).

Outputs were coded both quantitatively and qualitatively, structured into three methodological strands:

Descriptive bibliometric analysis (Research Questions 3 and 4): Participant characteristics, temporal patterns, geographic coverage, and the disciplinary backgrounds of contributing authors were extracted and analyzed. Collaboration patterns among researchers producing the included outputs were also examined.

Narrative synthesis (Research Questions 1 and 2): The lived experiences of athletes exposed to the WADC sanctioning framework were synthesized using a thematic summary approach (43). This synthesis drew on direct quotes from athletes as reported in the included outputs and the interpretations of those experiences provided by the original authors. Only data attributable to athletes with direct experience of the WADC sanctioning framework were extracted from outputs that included multiple participant groups to maintain analytic focus. No attempt was made to code or differentiate experiential data according to violation characteristics or athlete characteristics, including intentionality, as such distinctions were not consistently reported across included outputs and could not be reliably linked to individual experiential accounts. These accounts, both direct and interpreted, were then organized into recurring themes, points of divergence, and broader conceptual paradigms. Variation in context and richness of findings were retained rather than collapsed, supporting a nuanced account of athlete experiences. The coding and thematic development were initially conducted by the first author before being presented to and discussed with the other authors, ensuring transparency, consistency, and collective agreement in the synthesis.

Impact and connectivity analysis (Research Question 4): Within the context of this study, impact was defined as the combined academic visibility, disciplinary engagement, policy uptake, and conceptual emphasis of the field, measured through citation metrics and networks, policy citations and altmetrics, and keyword mapping. This definition was influenced by previous examinations of impact determinations (44, 45).

Academic impact was appraised using citation analysis, citation network analysis, and keyword mapping. Citation data were retrieved from Dimensions.AI, Scopus, and Clarivate (Web of Science). Citation frequency of each included output was analyzed quantitatively using raw citation counts, field-weighted citation impact (FWCI), and field citation ratios (FCR), which normalize citation counts relative to disciplinary and temporal baselines. Qualitative analysis examined the disciplinary orientation and thematic content of citing articles. The substantive nature of citations was also considered (e.g., methodological engagement vs. contextual acknowledgment). Citation relationships between the included outputs were analyzed using the edge list method (46) and visualized using network graphs with the Cytoscape network visualization tool (47).

Policy impact was assessed through Altmetric data, capturing citations in formal policy documents and grey literature, as well as broader online engagement beyond traditional academic metrics. Finally, authors’ keywords were compared with AI-extracted key terms from full texts using the Dimensions.AI algorithm to examine conceptual emphasis and identify potential blind spots.

Twenty-four outputs were identified as having potential relevance and compared against the inclusion and exclusion criteria (Figure 1). Following this process, twelve outputs were included in the final corpus (Table 1). Three of the twelve outputs were co-authored or supervised by members of the authorship group (25, 41, 42).

The corpus comprises nine peer-reviewed articles (24, 25, 35–40, 42), one PhD thesis chapter (41), one peer-reviewed book chapter (32), and one publicly available research report (23) (see Supplementary Table 3.1). The nine peer-reviewed articles were published in Performance Enhancement & Health (k = 3), Journal of Clinical Sport Psychology (k = 2), Journal of Physical Education and Sport (k = 1), Drugs: Education, Prevention and Policy (k = 1), Sport Management Review (k = 1), and International Journal of Sport Policy and Politics (k = 1).

Methodologically, nine outputs used individual interviews to capture the perspectives of athletes (23–25, 35, 38–42). Three outputs adopted case-based approaches: one was framed as an academically oriented case study published in a peer-reviewed journal (36), one was presented as a case study within a peer-reviewed book chapter (32), and one reported the perspective of a single athlete situated within a broader dataset (37).

Temporally, no outputs were published during the first iteration of the WADC (2004–2008). Four outputs (33.3%) were published during the second iteration (2009–2014): Kirby et al. (40), Piffaretti (23), Georgiadis & Papazoglou (24), and Henning & Dimeo (37). Two outputs (16.7%) were published during the third iteration (2015–2020): Engelberg et al. (35) and Erickson (36). Six outputs (50%) were published during the fourth iteration (2021–2025): Jamieson & Ordway (32), Shelley (41), van der Kallen et al. (42), Juma & Woolf (39), Hall et al. (25), and Huseynli et al. (38).

With a maximum possible quality score of 10, overall quality assessment scores of the individual raters ranged from 2.5 to 10. Across all raters, the mean quality assessment scores ranged from 4.67 (±0.8) to 10 (±0.0) (Supplementary Table 2.2).

The initial Inter Rater Reliability Score, based on the Fleiss’ Kappa value, was moderate with kappa = 0.41 [0.36–0.46] (48). Following discussion and revision, Fleiss’ Kappa value rose to 0.67 [0.60–0.72], which is interpreted as substantial (48). Subsequent analysis of weighted Cohen`s Kappa Analyses between the individual raters following the discussion were between moderate with kappa = 0.54 [0.33–0.75] and near perfect with kappa = 0.96 [0.92–1.00] (49); (Supplementary Table 2.3).

Generally, the authorship group identified congruence between research methodologies, output objectives, and data analysis. The voices of the athletes were also considered to be well represented throughout the analyzed outputs. However, best practices were not observed across the corpus regarding the reporting of the philosophical positioning and in situating the researchers culturally and/or theoretically, including how these factors may have influenced the research. During the quality assessment process, papers receiving lower scores were typically authored by individuals who had initially trained or worked in fields where qualitative methods are less commonly used.

Across the 12 outputs, the perspectives of 49 athletes were presented; however, the inclusion of the same athlete in more than one output could not be ruled out. Seven outputs presented the perspectives of athletes who had experienced the WADC sanctioning process in isolation (23–25, 32, 36, 39, 42), accounting for 34 athletes. The remaining five outputs included these athletes as part of broader samples (35, 37, 38, 40, 41), accounting for 15 athletes. Regarding the sanctioning status of participants, Engelberg et al. (35) included the perspectives of two athletes who had been “detected”, although it was not confirmed whether they were ultimately sanctioned. Henning and Dimeo (37) included one athlete who was indirectly exposed to the Article 10 sanctioning process through an unsuccessful Therapeutic Use Exemption (TUE) application but was never formally sanctioned. Huseynli et al., (38, p. 7) included athletes who had “undergone anti-doping proceedings in the last five years (pre-hearing, hearing, and/or appeal) or were serving a ban for having committed an ADRV”. In the remaining outputs, all athletes were explicitly reported as having been sanctioned for an Anti-Doping Rule Violation under the WADC.

The narrative synthesis suggests that the consequences associated with WADC sanctions extend beyond sporting implications and can emerge prior to the imposition of a formal sanction, fundamentally reshaping athletes’ lives. The following analysis maps these experiences, ranging from the initial uncertainty of investigations and acute psychological distress to the longer-term effects of social stigmatization, institutional abandonment, and the disruption of athletic identity.

Multiple outputs reported challenges relating to participant recruitment (23–25, 35, 39, 40, 42). Beyond the reporting of challenges, Juma & Woolf (39) and Piffaretti (23) outlined the specific barriers encountered. These included relevant participants not having the time to participate (23, 39), expressing a lack of interest (23), and being unreachable (23).

To complement the narrative synthesis and deepen understanding of the research landscape on athletes sanctioned under the WADC, this section presents findings from a bibliometric analysis of the included outputs. This analysis offers a meta-level perspective on the field's development, research patterns, and structural gaps. It maps publication trends over successive WADC iterations, compares author-supplied keywords with AI-extracted terms from Dimensions.AI to identify thematic emphases and conceptual divergences, and explores the disciplinary positioning of contributing authors. The section also evaluates the degree of scholarly collaboration through network analysis and assesses academic and policy impact via citation metrics and qualitative citation patterns. Together, these insights contextualize the field's epistemic structure and signal opportunities for future research development.

Figure 3 illustrates the citation relationships among studies included in this review, revealing a moderately interconnected but still loosely structured network. Unlike the fragmented co-authorship pattern (Figure 2), citation links indicate some intellectual continuity across time and research groups. Overall, the citation network suggests partial integration of knowledge with a few seminal studies providing foundation for researching sanctioned athletes’ experiences. Several early works serve as central nodes in the network. Kirby et al. (40) and Piffaretti (23) appear as key anchors, receiving multiple incoming links from later studies such as Erickson (36), Hall et al. (25), and Juma & Woolf (39). These connections suggest that foundational qualitative research on sanctioned athletes and psychological determinants continues to inform subsequent scholarship. Similarly, Engelberg et al. (35) occupies a bridging position, cited by both earlier and more recent outputs, including Henning & Dimeo (37) and Hall et al. (25), reflecting its relevance to policy and deterrence frameworks.

Despite these hubs, the network remains relatively sparse. Clusters such as Georgiadis & Papazoglou (24) and Shelley (41) show multiple citation ties, yet there are notable isolates like Jamieson & Ordway (32) and Huseynli et al. (38), which have no visible outbound or inbound links within this topic set. This pattern indicates that while some studies build on prior work, others emerge independently, limiting cumulative theory development. The absence of dense cross-referencing points to the need for greater synthesis and studies offering conceptual scaffolding.

This section presents an integrated assessment of the included outputs, using data from Dimensions.AI, Scopus, and Clarivate (Web of Science), to identify patterns in the scale and disciplinary reach of citation impact.

Studies examining behavioral, ethical, or performance-related dimensions of sport and health show measurable academic impact and interdisciplinary reach. Kirby et al. (40) and Engelberg et al. (35) each exceed 85 citations and rank in the top percentiles for field-weighted citation impact and field citation ratios (Supplementary Tables 4.1, 4.2). Both studies are cited across multiple disciplines, including psychology, sociology, pharmacology, and sport sciences (Supplementary Table 4.3). Altmetric data indicate broader visibility, with Engelberg et al. (35) appearing in policy documents and receiving diverse online engagement. Erickson (36) and van der Kallen et al. (42) show lower citation counts but remain visible through digital platforms. Recent outputs, including Hall et al. (25) and Huseynli et al. (38), have limited citation data but demonstrate early online attention.

Citation network analysis (Figure 3) indicates a moderately interconnected field. Kirby et al. (40) and Engelberg et al. (35) serve as central nodes, with Kirby et al. (40) exhibiting the highest in-degree centrality. Juma & Woolf (39) and Erickson (36) show higher out-degree centrality, reflecting engagement with prior studies. Qualitative citation content analysis (Supplementary Table 4.4) shows variation in citation usage: some references are embedded in methods, discussion, or research rationale, whereas others serve primarily as acknowledgements. For example, van der Kallen et al. (42) and Juma & Woolf (39) cite Kirby et al. (40) and Piffaretti (23) to support research design and findings, whereas Erickson (36) and Shelley (41) cite these studies primarily for contextual background.

In terms of policy impact, past research had little documented traction. Engelberg et al. (35) was the only output identified as being cited in formal policy documents, appearing in a European Commission report on the use of anabolic steroids and human growth hormones in sport (Supplementary Table 4.3). No other outputs were found to have direct citations in policy literature. However, this limited visibility does not necessarily reflect the full extent of influence. Research in this area may have informed policy thinking or practice through informal channels (e.g., expert consultations, workshops, or internal reports) that are not captured through bibliometric tracking. While such pathways to impact or at least influence are likely, their impact remains undocumented and difficult to systematically assess within the scope of this analysis.

The integration of findings from this study with those of Hong et al. (76), which highlighted limited organizational support for athletes sanctioned under the WADC, reinforces the presence of a definable and systemic gap in care provision for athletes who are exposed to the WADC sanctioning framework. Based on the testimonies examined in this review, this population is currently being overlooked despite the expansion of interventions aimed at enhancing athlete welfare (77, 78). Whilst the existence of this unmet need is problematic, it also offers organisations such as WADA an opportunity to develop a support system from the foundations upwards rather than amending legacy frameworks, which could pose challenges due to barriers relating to policy innovation (79–82). As part of this foundational development, there is also a need to develop an understanding of which organizations have or could inherit a responsibility for providing care for this population of athletes.

A logical starting point is the responsibility of WADA as the primary policy maker and overseer within global anti-doping governance, specifically in relation to how the aims of sanctioning are articulated and justified. Whilst the WADC (5) outlines the rationale for anti-doping regulation, provides a harmonized definition of doping, and describes how to sanction athletes, limited attention is given to clarifying the broader purposes of sanctioning, creating uncertainty regarding the intended outcomes of periods of ineligibility for those who experience them. This ambiguity persists in the latest iteration of the WADC, which comes into effect in 2027; however, anti-doping is now explicitly framed as “primarily an ethical position based on a vision of the spirit of sport” (83). Framing anti-doping in ethical terms strengthens the normative basis of sanctioning but also elevates expectations that the system attends to the wider consequences experienced by sanctioned athletes, rather than limiting its focus to rule enforcement alone. As a legitimacy-based authority (1, 2), WADA therefore carries responsibility not only for maintaining perceptions of the World Anti-Doping Program, but also for anticipating and mitigating unintended harms arising from the application of its rules (8). This includes ensuring that sanctioning practices align with principles of transparency, accountability, proportionality, and fairness (2, 7), and that the purposes of Article 10 are sufficiently articulated to those subject to it.

Whilst this review has primarily focused on athletes’ lived experiences through the lens of perceived legitimacy, WADA also carries responsibilities under the World Anti-Doping Program to uphold the rights and protections of the athletes it governs, reflecting both regulatory and legal obligations. Recent developments illustrate this dual dimension. WADA has initiated a Human Rights Impact Assessment to examine how the World Anti-Doping Program intersects with the human rights of athletes (13). Led by an independent expert, the assessment aims to identify risks and ensure that anti-doping governance aligns with internationally recognised human rights standards, complementing broader efforts to sustain legitimacy and safeguard athletes throughout the sanctioning process. Alongside this internal review, external legal scrutiny has also emerged. The Advocate General's opinion before the Court of Justice of the European Union in Case C-474/24 questioned whether the systematic publication of athletes’ names, sporting discipline, sanction length, and reasons for sanction may be disproportionate (84). The opinion pointed towards alternatives such as pseudonymized publication or more targeted disclosure to relevant bodies, balancing transparency with data protection considerations. Taken together, these developments indicate that WADC sanctioning practices are being evaluated not only in terms of perceived legitimacy, but also against legal and organizational standards, reinforcing the relevance of this issue for WADA in sustaining legitimacy and fulfilling its governance responsibilities.

Alongside WADA, signatory organizations to the WADC carry direct responsibility for the implementation of anti-doping rules in practice. NADO, International Federations, Regional Anti-Doping Organizations, and accredited laboratories are responsible for translating the WADC into operational procedures across testing, education, results management, and sanctioning. These responsibilities are exercised within diverse socio-geographic, political, organizational, and resource contexts, requiring signatories to manage variation while maintaining compliance with the standards of the World Anti-Doping Program (1, 4). As the primary point of contact between the anti-doping system and athletes, signatories are responsible not only for technical compliance, but also for sustaining legitimacy through their everyday practices (85). This includes acting transparently in testing and sanctioning procedures, maintaining accountability in decision-making processes, and applying sanctions in a proportionate and consistent manner. Signatories also hold responsibility for protecting the independence of anti-doping processes from political or organizational interference and for clearly communicating their roles, obligations, and procedural steps to athletes (86). Where capacity constraints exist, signatories are responsible for pursuing collaboration, information-sharing, and capacity-building mechanisms, including bilateral agreements, to ensure that standards are met in practice (87). Through the clear articulation and consistent enactment of these responsibilities, signatories play a central role in maintaining the legitimacy of the anti-doping regime among athletes and in shaping how the WADC is experienced in everyday sporting contexts.

Despite these responsibilities, the testimonies analyzed in this review suggest that neither WADA nor WADC signatories are well positioned to deliver the forms of pastoral or welfare-oriented support that sanctioned athletes describe as necessary. This limitation reflects not only resource constraints, but more fundamentally the structural tensions inherent in organizations that combine regulatory, investigative, and adjudicative functions. When bodies responsible for imposing and enforcing sanctions are also positioned as providers of care, concerns relating to fairness, transparency, and psychological safety may arise, with implications for how legitimacy is perceived by athletes (24, 38). Recent institutional developments, including the delegation of testing and results management functions to bodies such as the International Testing Agency and the Athletics Integrity Unit, have sought to enhance transparency and accountability within the World Anti-Doping Program. However, while these arrangements introduce greater institutional separation from sport governing bodies, they do not resolve the underlying tension between sanctioning authority and care provision, as these organizations remain embedded within the enforcement architecture of the WADC and continue to exercise investigative and regulatory power. Structural independence from sport organizations therefore does not, in itself, address the conflict of interest that arises when sanctioning bodies assume responsibility for athlete support. The findings indicate a need to consider forms of provision that are functionally independent from the sanctioning process altogether, with organizations external to the World Anti-Doping Program potentially better positioned to provide support that is perceived as impartial and safe, while allowing regulatory bodies to retain a clear focus on enforcement and compliance.

Some may argue that post-sanction support undermines deterrence or that committing an ADRV entails forfeiture of assistance. While deliberate doping justifies robust sanctions under strict liability, athletes should not be treated as uniformly malicious, as doping behaviors are shaped by structural pressures, power asymmetries, and normalized risk-taking cultures in elite sport (88–91). These dynamics are particularly evident in systemic doping, where athletes may operate in coercive environments, rendering them simultaneously rule violators and victims [e.g., (92, 93)]. Ethical critiques further note that strict liability separates sanctioning from moral culpability and does not negate welfare obligations (67). Proportionate post-sanction support aligns with broader criminal justice practices, where individuals convicted of serious offences commonly receive structured rehabilitation and reintegration support (94, 95), and may enhance compliance by strengthening procedural legitimacy (2). Yet, no stakeholder is clearly responsible for sanctioned athletes’ welfare. Although the WADC details sanctioning procedures, it does not assign responsibility for psychosocial, medical, or reintegration support (5). This governance gap may compound harms that extend beyond ineligibility to include stigma, identity disruption, and psychological distress, irrespective of intent (96, 97). The gap is especially salient in unintentional ADRVs. Analogous to harm-reduction approaches in recreational drug use policy (83), targeted, Code-compliant support that maintains athletes’ connection to sport may mitigate secondary harms and protect long-term investments in athlete development (98–100).

Addressing this gap would require mapping the transition in duty of care from sanctioning authorities at adjudication through to the completion of a period of ineligibility. Such mapping would clarify which organizations are positioned to provide specific forms of support and enable the development of coordinated, clearly defined pathways. Potential contributors include players associations, which can advocate for athlete interests and provide peer support; national health services and independent mental health providers, which can deliver clinical interventions separate from adjudication processes; clubs and teams, which maintain ongoing relationships with athletes; and independent athlete welfare bodies. Further research should examine the appetite, capacities, and resource limitations of these organizations to determine their readiness and willingness to participate in coordinated care provision. Empirical examination of how athletes experience transitions across different phases of sanctioning would illuminate critical moments when support is most needed. Establishing such frameworks would directly address the welfare gap identified in this review, ensuring that sanctioned athletes receive support that complements the enforcement aims of the WADC and aligns with broader commitments to athlete wellbeing.

Several limitations of this review must be acknowledged. As a review of secondary data, the analysis was shaped by what was reported in the included outputs and, therefore, reflects how previous authors have documented athletes’ experiences of the WADC ADRV sanctioning process, rather than providing an assessment of the accuracy of those accounts or offering interpretations beyond what is available in the published evidence base.

The exclusive inclusion of peer-reviewed academic outputs represents a further limitation. While this approach ensured a consistent and standardized level of quality and rigor, it excluded grey literature and other non-peer-reviewed sources, including media accounts, reports produced by advocacy organizations, and legal or disciplinary documents. Perspectives that fall outside academic publishing conventions are therefore underrepresented. Consequently, the findings reflect the perspectives documented within peer-reviewed research and do not encompass the full spectrum of experiences that may exist outside the academic literature.

The restriction to English-language publications constitutes an additional limitation. This decision was determined by the languages spoken within the research team and concerns that selectively including additional languages could introduce bias by privileging particular linguistic contexts. Consequently, the review is likely to have captured fewer culturally and geographically diverse perspectives than have been described within academic literature.

Uncertainty remains regarding whether the same sanctioned athletes contributed to multiple included studies. Recruitment challenges reported across the evidence base indicate that participant overlap cannot be ruled out, meaning that the cumulative findings may reflect the experiences of fewer individuals than aggregate sample sizes suggest.

A further limitation concerns the interpretation of synthesized athlete experiences in relation to anti-doping rule violations. The experiences presented across the included studies should not be read as providing insight into athletes’ lived experiences in relation to intentional or unintentional ADRVs, as this distinction was not consistently reported or analytically preserved at the individual level. Instead, the synthesis reflects broader and often decontextualized accounts of athletes’ perceptions, challenges, and interactions with the WADC sanctioning process and its related impacts, which are not systematically anchored to adjudicated violation outcomes. Three exceptions were identified (24, 32, 42). The first two examined athletes’ lived experiences in relation to ADRVs reported as unintentional, while the latter included athletes who had admitted to intentional violations. Beyond these cases, the remaining studies did not explicitly examine lived experiences in relation to violation intent. Even where aggregate proportions of intentional vs. unintentional ADRVs were reported, this distinction was not preserved at the anonymized individual level. Consequently, specific experiential accounts or verbatim quotations cannot be meaningfully linked to the intentionality of the violation, constraining the interpretive precision of the synthesis. Taken together, the findings are best understood as reflecting general athlete experiences within anti-doping contexts, rather than direct representations of the lived experiences of athletes sanctioned for intentional or unintentional ADRVs.

Finally, the synthesis itself is influenced by factors inherent to the review process. Selection of quotations and thematic coding involve interpretation, and publication bias may affect the available evidence, as peer-reviewed literature could preferentially report cases with more compelling or pronounced findings, potentially underrepresenting less extreme experiences. Variability in how experiences were documented across studies, including differences in qualitative methods, level of detail, and analytic focus, may also influence the comparability and richness of the synthesis.

The current review provides a foundational understanding of the lived experiences of athletes exposed to the WADC. However, important opportunities for future research remain. Expanding the range of athlete perspectives following sanctions should be a priority. Limited gender and geographic representation currently constrains insight into how sanctioning processes and their consequences may differ across population groups. Moreover, none of the athletes represented across the twelve outputs were explicitly sanctioned for technical violations such as whereabouts failures or evasion. It therefore remains unclear whether these types of infractions lead to distinct lived experiences. Including a broader range of athletes would allow exploration of underrepresented experiences and provide a stronger foundation for evidence-informed policy development. Expanding the sample beyond previously studied groups would also enable the design of interventions that are better tailored to diverse athlete needs, which is particularly important in a top-down regulatory environment where policies and support mechanisms are standardized. Calls for broader coverage of ADRVs (beyond use and presence), as well as greater geographical representation, have consistently been made in the anti-doping field (51, 88). Capturing a wider array of experiences would allow researchers and policymakers to identify variation in sanction perception, the challenges athletes face, and the supports required, enabling interventions to be more responsive, equitable, and effective across populations.

Enhancing the interpretability of this body of research, while respecting participant anonymity, is a further priority. Academics should carefully balance the reporting of demographic and contextual variables with protection of participant identity. Where ethically feasible, reporting variables such as age at sanction, gender, nationality, geographic location, sport type and level, career stage, procedural details including legal representation during hearings, and whether the athlete returned to sport, could provide valuable context to support evidence synthesis and policy decision-making. Developing guidelines for ethical reporting that balance transparency with protection would support the creation of a more comprehensive, culturally and geographically diverse dataset. Across all research activities, psychological safety, confidentiality, and reciprocal value for participants should be prioritized, with trauma-informed approaches mitigating risks of stigma, reputational harm, or professional repercussions. From a methodological perspective, maintaining rigor when collecting and reporting the perspectives of athletes who have experienced WADC sanctions should incorporate qualitative expertise and adherence to established quality criteria, including credibility, dependability, confirmability, and transferability (101), with the adoption of structured assessment tools potentially assisting with this (31).

Athletes exposed to the WADC remain a hard-to-reach population, as reflected in most outputs included in this review. This underscores the need for methodological innovation beyond traditional social science approaches. Alternative, publicly available sources offer promising avenues for addressing recruitment challenges, including case studies (37, 102), online forums (103, 104), social media (105, 106), print media (107–109), and document analysis (110, 111). Building on these approaches, there may also be scope to introduce formal mechanisms within anti-doping processes that enable athletes to document or communicate experiences in real time. Examples could include anonymized reflective journals, structured debriefs, or confidential testimony submitted to an independent body, which could provide valuable qualitative insight for researchers and policymakers while supporting athletes’ psychological wellbeing.

Future research should also examine organizational and systemic perspectives to build a holistic understanding of the sanctioning ecosystem. Investigating how anti-doping bodies implement policies, provide support, and use research evidence to inform practices may clarify facilitators and barriers to effective duty of care models. Organizational representatives are rarely included in anti-doping research, which limits insight into these processes (112). Understanding whether organizations have drawn on research findings when formulating policies, targeted education programs, or support mechanisms is particularly important. Equally, exploring barriers to consulting existing evidence could provide valuable insight. While the WADC mandates minimum compliance requirements, some organizations have implemented additional measures, for example separately regulating and testing for social drugs (76, 115), providing financial legal aid in some countries (114), offering mental health support for sanctioned athletes, involving former sanctioned athletes as educators and clean sport ambassadors, or delivering additional education for emerging athletes (76, 115). Understanding the extent to which these initiatives are research-based or research-informed, and how they support athletes who access these services, would inform future research and facilitate collaboration between academic researchers and practitioners.

Critically, future research should aim to clarify the purpose and intended function of WADA sanctions, including how sanctions are designed to achieve compliance, deter violations, and uphold legitimacy. Once this understanding has been developed, questions of responsibility for responding to these insights emerge. Whether this responsibility lies with WADA, national agencies, international federations, or a coordinated global approach remains open, but addressing it is necessary for reforms to move beyond acknowledgement toward meaningful action. Integrating organizational insights with a deeper understanding of sanctioning objectives would help ensure that policy and practice reforms are effective, coherent, and aligned with the principles of fairness, deterrence, and legitimacy, while also facilitating more complete policy analysis, which typically involves defining the problem the policy is intended to address and the criteria for evaluating its success (116).

To strengthen the evidentiary foundation of research involving sanctioned athletes, future studies should adopt more transparent and systematic reporting practices within ethical confidentiality. The current lack of detail regarding the nature of ADRVs significantly limits the potential for meaningful comparisons, systematic reviews, and secondary data analysis. Researchers are strongly encouraged to include anonymized participant profile tables that provide essential contextual information. At a minimum, these should include gender, sport, country of residence or nationality, ADRV type, and length of sanction. Additional information, such as career progression after serving an ineligibility period or information on the testing and sanctioning authority, would add further context. Such additions would not only enhance the interpretability of findings but also support the cumulative development of knowledge and evidence-informed policy in the anti-doping field.

Finally, the isolated nature of research on WADC sanctions limits opportunities for theoretical development, longitudinal tracking, and comparative studies (56), leaving the field vulnerable to knowledge silos and slow conceptual progress. Future research could therefore adopt meta-research approaches to examine the structure and processes of the research community itself. Investigating how research is organised, how questions are prioritised, and the barriers to collaboration and knowledge integration could clarify why these structural limitations exist and help identify strategies to foster more coordinated, cumulative, and policy-relevant knowledge production.